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*The free!,dobe Reader may be used to view and compl s fo, However,software must be purchased to complete,And reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fill In <br /> ilJell Completion Report �� 'E7 <br /> Page 1 Of 1 Refer to Instruction Pamphlet ( I <br /> State Well Number/Site Number <br /> Owner's Well Number VW-1 _ No. e0240984 <br /> Date Work Began 10/30/2014 Date lVo k 'nded 10/30/2)14 -" Latitude t Longe <br /> de -vv <br /> Local Permit Agency San Joaquin County Envirollm ti ill Health Department I I I I I I <br /> Permit Number 0070825 Permit Da r, 1 C 10/14 APNITRS/Other <br /> Geologic Lam_ Well Owner <br /> Orientation OVertical 0Horizontal ;)/.nc Specify_ Name Jim Weber <br /> Drilling Method Hollow Stem Auger Dri lin I =Iuid <br /> Mailing Address 2229 Manzanita Court <br /> Depth from Surface Descrip io Lodi CA 95242 <br /> Feet to Feet Describe material,-Irai i s; color,etc Cit State—Zi <br /> 45 0 Drill Sample Install Well Location <br /> 2" Diameter Wells using E." Flo 1:>w Stem Auger Address 230 N Church St <br /> See well materials s City Lodi County San Joaquin <br /> Latitude N Longitude �N <br /> Deq Min Sec. Deq. Min. Sec. <br /> -- V4Datum Dec. Lat. 38.13772 Dec.Long.-121.27468 <br /> APN Book 043 Page 023 Parcel 01 <br /> Township —Range Section <br /> EMAIR �C Location Sketch Activit <br /> Sketch must be drawn by hand after form isprinted.) Q New Well <br /> North 0 ModincationiRepair <br /> —_-. O Deepen <br /> O Other <br /> -- O Destroy <br /> Describe procedures and materials <br /> under`GEOLOGIC LOG` <br /> — Planned Uses <br /> -- O Water Supply <br /> -- ❑Domestic ❑Public <br /> -- w <br /> []Irrigation []Industrial <br /> — O Cathodic Protection <br /> --- O Dewatering <br /> ---. O Heat Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> N O Sparging <br /> South O Test Well <br /> m s -- 0 Vapor Extraction <br /> Illustrate or describe distance of well from roads,buildings,fences. <br /> — _ rivers.etc.and attach a map Use additional paper if necessary. 0 Other <br /> Please be accurate and complete <br /> --" Water Level and Yield of Completed Well <br /> -- Depth to first water (Feet below surface) <br /> --- Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 45 __ _ Feet Estimated Yield' (GPM) Test Type <br /> Total Depth of Completed Well 45 _ Feet Test Length (Hours) Total Drawdown (Feet) <br /> Ma not be representative of a well's long term yield. <br /> _ CasiniL_ Annular Material <br /> Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feet to Feet <br /> 45 15 8 Screen PVC Sch.40 __ 2 Milled Slots 0.030 45 13 Filter Pack #3 sand <br /> 15 0 8 Blank 2 13 11 Bentonite chips <br /> 11 0 Cement Portland 1/11 <br /> Attachments __ Certification Statement <br /> El Geologic Log I thl,L r iersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑ Well Construction Diagram I. 3n e _,UI Well Abandonment, Inc. <br /> Person.Firm or Corporation <br /> El Geophysical Log(s) 3330 Fitzgerald Road SLLte B -:;Rancho Cordova CA 95742 <br /> ❑ Soil/Water Chemical Analyses Addresit ., City State zip <br /> ID Other Site Mal) :igrec -,�^""�, '> 11/11/2014 848359 <br /> Attach additional information if it exists. = ntractor Date Signed C-57 License Number <br /> DWR 188 REV 112006 IF AD Ali NAL SPACE-t NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />